Laserfiche WebLink
Ot <br /> INSTRUCTIONS FOR COMPMrITNG, FORM'B" <br /> GENERAL INSTRUCTIONS: <br /> 1. One FORM"B"shall be completed for each tank for all NEW PF1RMrl-Z,,PFRMrJI'(-TtANGIN, REMOVAI-Sand/car any <br /> other TANK INFORMATION CHANGE <br /> 2. This form should be completed by either the PERMIT APPLIC/U11-1"or the LOCAL AGENCY UNDERGROUND TANK <br /> INSPECIX)R. <br /> 3. Please type or print clearly all requested information. <br /> 4. Use a hard point writing instrument,you are making 3 copies. <br /> TOP OF FORM:*MARK ONLY ONE ITEM* <br /> 1. Mark an(X)in the box next to the item that best describes the reason the form is being completed. <br /> 2. Indicate the DBA or Facility name whew the tank is installed. <br /> I. TANK DESCRIPTION-WMPIZILI All,T1`EMS-IF UNKNOWN-SO SPI-XJF`Y <br /> A. Indicate owners tank ID# -If there is a tank number that is used by the owner to identify the tank(ex.AB70789), <br /> B. Indicate the name of the company that manufactured the tank(cx.ACME,"I'ANK MFG.). <br /> C. Indicate the year the tank was installed (ex. 1987). <br /> D. Indicate the tank capacity in gallons(ex. 25,000 or 10,0M ctc.). <br /> II. TANK COMJIWrS <br /> A. 1. If MOTOR VEHIC11f, FUEL,check box 1 and complete items B & C <br /> 2.If.not MOTOR VEHICLE FUEL,check the appropriate box in section A and complete items B Sr D. <br /> B. Check the appropriate box. <br /> C. Check the type of MOTOR VEHICLF FUEL(if box 1. is checked in A). <br /> D. Print the chemical name of the hazardous substance stored in the tank and the C,A.S.#. (Chemical Abstract Service <br /> number),if box I is NOT checked in A. <br /> III- TANK CONSTRUCTION-MARK ONE ITEM ONLY IN BOX A,B,C,&D <br /> 1. Check only one item inTYPE OF SYSTEM,TANK MAFI`,RIAL, INFERIOR LINING and CORROSION PRO'IT7C`rION. <br /> 2. If OTHER,print in the space provided. <br /> IV. PIPING INFORMATION <br /> 1. Circle A if above ground; circle U if underground;and circle both if applicable. <br /> 2. If UNKNOWN,circle;or if OTHER,print in space provided. <br /> dk 3. Indicate the LEAK DEI'EcriON system(s) used to comply with the monitoring requirement for the piping. <br /> V. IANK LEAK DUII31711014 <br /> 1. Indicate the LEAK DEUECTIONsystem(s) used to comply with the monitoring requirements for the tank. <br /> VI. INFORMATION ON TANK PERMANEM11.Y CLOSED IN PLACE, <br /> 1. ESTIMAITO DATE LAST USED-MONTIT/Yf`�AR(January, 1988 or 01/88). <br /> 2. 12S111%4ATED QUANITI'Y of HAZARDOUS SUBSTANCE' remaining in the tank (in Gallons). <br /> 3. WAS TANK FILLED WITH INT I;rr MNFERIAL? Check'Yes' or'NO'. <br /> APPLICANT MUST SIGN AND DA117,11111 FORM AS INDICATI0. <br /> INSTRUCTION FOR 1.1113 LOCAL AGENCIES <br /> The state underground storage tank identification number is composed of the two digit county number, the three diait juris-diction <br /> number, the six digit facility number and the six digit tank number. The county and jurisdiction numbers are predetermined and <br /> can be obtained by calling the State Board(916)739-2421_ The facility number must be the same as shown in form "A". The <br /> tank number may be assigned by the local agency; however, this number must be numerical and cannot contain an alphabet. If <br /> the local agency prefers the Stage Board to assign the tank number,please leave it blank. <br /> 11'IS THE RESPONSIBILTI'Y OF 111E LOCAL AGENCY 1I 1ATINSPIX.71"S11111 FACILITY TO VERIFY'17-113 <br /> ACCURACY OFIIIE INFORMATION. IIID LOCAL AGENCY VS ROSPONSIBIJ!FORIIIE COMP111,11ON OF 771E <br /> 'LOCAL AGENCY USE ONLY"INFORMATION BOX AND FOR FORWARDING ONE FORM*A"AND ASSOC IA713.1) <br /> FORM'W(s)TO 11111 FOI1,OWING ADDRESS. <br /> SrAlli OF CALIFORNIA <br /> STAII!WATER RESOURCES CONTROL BOARD <br /> C/O S.W.Lz E.P.S. <br /> DATA PROCESSING CENTER <br /> P.O.BOX 527 <br /> PARAMOUNT,CA 90r723 <br />